Gandré Coralie, Gervaix Jeanne, Thillard Julien, Macé Jean-Marc, Roelandt Jean-Luc, Chevreul Karine
URC Eco, Hotel Dieu, 1 place du Parvis Notre-Dame, 75004 Paris, France,
J Ment Health Policy Econ. 2018 Mar 1;21(1):17-28.
Inpatient psychiatric readmissions are often used as an indicator of the quality of care and their reduction is in line with international recommendations for mental health care. Research on variations in inpatient readmission rates among mental health care providers is therefore of key importance as these variations can impact equity, quality and efficiency of care when they do not result from differences in patients' needs.
Our objectives were first to describe variations in inpatient readmission rates between public mental health care providers in France on a nationwide scale, and second, to identify their association with patient, health care providers and environment characteristics.
We carried out a study for the year 2012 using data from ten administrative national databases. 30-day readmissions in inpatient care were identified in the French national psychiatric discharge database. Variations were described numerically and graphically between French psychiatric sectors and factors associated with these variations were identified by carrying out a multi-level logistic regression accounting for the hierarchical structure of the data.
Significant practice variations in 30-day inpatient readmission rates were observed with a coefficient of variation above 50%. While a majority of those variations was related to differences within sectors, individual patient characteristics explained a lower part of the variations resulting from differences between sectors than the characteristics of sectors and of their environment. In particular, an increase in the mortality rate and in the acute admission rate for somatic disorders in sectors' catchment area was associated with a decrease in the probability of 30-day readmission. Similarly, an increase in the number of psychiatric inpatient beds in private for-profit hospitals per 1,000 inhabitants in sectors' catchment area was associated with a decrease in this probability, which also varied with overall sectors' case-mix characteristics and with the level of urbanisation of the area.
The extent of the variations and the factors associated with it question the adequacy of care and suggest that some of them may be unwarranted. Our findings should however be interpreted in consideration of several limits inherent to data quality and availability as we relied on information from administrative databases. While we considered a wide range of factors potentially associated with variations in 30-day readmissions, our model indeed only explained a limited part of the variations resulting from differences between sectors.
Our findings underscored that practice variations in psychiatry are a reality that merits the full attention of decision makers as they can impact the quality, equity and efficiency of care. A specific data system should be established to monitor practice variations in routine to promote transparency and accountability.
Few associations were found between variations in 30-day inpatient readmissions and the supply of care. The routine collection of detailed organizational characteristics of health care providers at a national level should be supported to facilitate additional research work, both in France and in other contexts.
住院精神科再入院率常被用作医疗质量的指标，降低该指标符合国际精神卫生保健建议。因此，研究精神卫生保健提供者之间住院再入院率的差异至关重要，因为当这些差异并非由患者需求差异导致时，会影响医疗的公平性、质量和效率。
我们的目标一是在全国范围内描述法国公立精神卫生保健提供者之间住院再入院率的差异，二是确定这些差异与患者、医疗保健提供者及环境特征的关联。
我们利用来自十个国家行政数据库的数据对2012年进行了一项研究。在法国国家精神科出院数据库中确定了住院护理的30天再入院情况。通过对数据的层次结构进行多级逻辑回归，以数字和图形方式描述了法国各精神科部门之间的差异，并确定了与这些差异相关的因素。
观察到30天住院再入院率存在显著的实践差异，变异系数超过50%。虽然这些差异大部分与部门内部差异有关，但个体患者特征对部门间差异导致的变异解释程度低于部门及其环境的特征。特别是，部门服务区域内躯体疾病死亡率和急性入院率的增加与30天再入院概率的降低相关。同样，部门服务区域内每1000名居民中私立营利性医院精神科住院床位数量的增加与该概率的降低相关，该概率也因部门总体病例组合特征和该地区城市化水平而异。
差异的程度及其相关因素对医疗的充分性提出了质疑，并表明其中一些差异可能是不必要的。然而，考虑到数据质量和可获得性的一些固有局限性，我们的研究结果应予以解释，因为我们依赖行政数据库中的信息。虽然我们考虑了与30天再入院差异潜在相关的广泛因素，但我们的模型实际上仅解释了部门间差异导致的变异的有限部分。
我们的研究结果强调，精神科的实践差异是一个现实，值得决策者充分关注，因为它们会影响医疗的质量、公平性和效率。应建立一个特定的数据系统来定期监测实践差异，以提高透明度和问责制。
在30天住院再入院差异与医疗供应之间发现的关联很少。应支持在国家层面常规收集医疗保健提供者详细的组织特征，以促进法国及其他背景下的更多研究工作。
